Boundaries Patient Registration Form

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 23/01/2023

Patients Details

NHS number

Title *

Surname *

First name(s) *

Previous Surname

Sex *

Male

Female

Date of Birth *

Full Address *

Postcode *

Email address *

Main Contact Telephone Number *

Secondary Telephone Number

Are you happy to be contacted by text message?

Yes No

Please provide the name, address and contact number for you Next of Kin *

I am a student at:

Please help us trace your previous medical records by providing the following

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

Do you have a non-UK EHIC or PRC?

Yes No

If yes, please enter details from your EHIC or PRC below:

Country Code:

Name:

Given Names:

Date of Birth

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period

a) From:

b) To:

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

I have an S1 form

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

If you are returning from the armed forces

Are you a Military Veteran?

Yes No

For Serving Personnel what is your Service Number

Are you a Family Member of a Serving member or veteran?

Yes No

Communication Needs

Carer Details

Are you a carer?

Yes No

If Yes are you:

Do you have a carer?

Yes No

Your Carer's name

Your Carer's Telephone Number

Your Carer's Relationship to you

Medical History

NHS Organ Donor Registration

Organ donation in England has changed to an opt out system. for further information please go to https://www.organdonation.nhs.uk/.

NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

I am already a blood donor

Yes No

I wish to be a blood donor

Yes No

I do not wish to be a blood donor

Yes No

Family History

Please record any significant family history of close relatives with medical problems and confirm which relative, e.g. mother, father, brother, sister, grandparent.

Allergies

Please record any allergies or sensitivities

Medication

Please give us your previous repeat medication list (note a medication review appointment may be needed)

Your Lifestyle - Alcohol

The score for each response if given in brackets. If you score 5 or more in total for the these questions please complete the Alcohol Audit Questions. One unit of alcohol = small glass of wine, half a pint of beer/cider/lager, single measure of spirits, small glass of sherry, single measure of aperitif. Note 330ml bottle or can = 1.5 units.

Alcohol Audit Questions

Please complete these question if you have scored 5 or more in total from the above section

Your lifestyle - Smoking

About you

Height? *

Weight and unit of weight, e.g. stones/pounds, kilograms? *

Waist Circumference, and units measured in, e.g. inches, centimeters? *

Women Only

Do you use contraception?

Yes No

Do you have a coil or implant in situ?

Yes No

Are you currently pregnant or think you may be?

Yes No

Students Only

I am less than 24 years old and have had two doses of MMR vaccination.

Yes

Unsure

I am less than 25 years old and have had a Meningitis C vaccination.

Yes

Unsure

Electronic Prescribing

If you would like your prescriptions to be sent electronically please provide details of the pharmacy you would like to use:

Patient Participation Group

Would you like to be involved in our Patient Participation Group - we are committed to improving the servcies we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Would you like to be involved in our Patient Participation Group ? *

Yes No

Sharing Your Health Record

A Summary Care record is used by staff caring for someone about their medicines and allergies. This means they can look after the person if they are not at their usual doctor’s surgery.

Do you consent to your GP Practice sharing your health record with other organisations who care for you, e.g. hospital? *

Yes No

Do you consent to your GP Practice viewing your health record from other organisations that care for you? *

Yes No

Do you consent to having a Summary Care Record? *

Yes No

Online Access to your Health Record

For further guidance please see our information sheet - Access to GP Online Services.

I wish to have onlne access to: *

View and book appointments

View and request medication

Access my coded medical record (contains any medical codes that have been recorded)

Access to my full medical record (contains medical codes and any free text that has been recorded

Access to my Summary Care Record

Complete online questionnaries

I do not require online access

I wish to access my medical record and understand and agree with; I have read and understood the ‘Important Information’ section below; I will be responsible for the security of the information that I see or download; If I choose to share my information with anyone else, this is at my own risk; I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement; If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible. *

I agree

Not applicable as I do not wish access

Complete Registration

Confirmation *

I confirm that the information I have provided is true and to the best of my knowledge.

Name of the person completing this form if different from the person registering

Relationship of person completing this form if not the person registering

Date *

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